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\begin{document}
% Copyright (C) Johan Michael van Schalkwyk, 2005 (J van Schalkwyk)
% This code is released under the Gnu Public Licence (GPL), a copy of which can
% be obtained at:
% \href{http://www.gnu.org/copyleft/gpl.html}{http://www.gnu.org/copyleft/gpl.html}.
% Please note the conditions of this licence.
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\hyphenation{Failure renal}
\begin{titlepage}
{
\font\fred=cmr10 at 10truept
\fred
\font\jane=cmr10 at 9truept
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{\fontfamily{pag}\fontsize{20}{0pt}\selectfont Analgesia safety checklist{\tiny{\raisebox{5mm}{RTM}}}}
\begin{tabular}{p{26mm}@{}cp{13.5mm}@{}c@{}p{11mm}@{}c@{}p{2mm}@{}p{12mm}@{}cp{20mm}cr@{}}
\hline
\multicolumn{12}{l}{} \\[-6mm]
\multicolumn{12}{@{}r@{}}{\fontfamily{pag}\fontsize{9}{9pt}\selectfont
\framebox{Y}~ \emph{unusual} positive.\hspace{3mm}\framebox{Y}~\hspace{-1mm}\framebox{N}~ choice between yes and \emph{significant} negative.
Only tick once you've checked
\framebox{Y\hspace{0.7mm}}\hspace{-4.5mm}\raisebox{0mm}{\huge \checkmark}}\hspace{-4mm} \\
\multicolumn{11}{l}{} \\[-2mm]
Failure:~renal\ldots & \framebox{Y} &
heart\ldots & \framebox{Y} &
~~~~~lung\ldots & \framebox{Y} & &
liver\ldots & \framebox{Y} &
Chronic~pain: & \framebox{Y} &
Chronic opiates:~~\framebox{Y}\\[3mm]
anticoagulated: & \framebox{Y} &
\multicolumn{3}{l@{\hspace{1mm}}}{other coagulopathy\ldots} &
\framebox{Y} & &
\multicolumn{4}{@{}l}{Ward/Bed:} \\[-1mm]
\cline{8-12}
\multicolumn{12}{l}{\raisebox{-3mm}{allergies/comment:}\vspace{-2mm}} \\
\end{tabular}
\vskip 7pt
% ===========================================================================================
\begin{tabular}{|@{\hspace{1mm}}p{15mm}@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}p{19mm}p{19mm}p{17mm}p{14mm}|p{18mm}|}
\hline
\multicolumn{9}{|c|}{~\vspace{-4.8mm}}\\
\cline{1-9}
\multicolumn{4}{|@{\hspace{1mm}}c|}{\textsf{\small date\raisebox{0.1mm}{\footnotesize\hspace{0.1mm}+}time}~~~} &
\multicolumn{1}{@{}c@{}}{\textsf{\small consultant}} &
\multicolumn{3}{|l|}{\hspace{16mm}\textsf{\small pain\footnotesize{/10}}~~~~~~~~~~} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}||}{\raisebox{-1mm}{\textsf{PCEA {\jane or} PCA}}}
\\[-3mm]
\multicolumn{2}{|c}{\raisebox{-3.5mm}{\large{\hspace{5mm}\raisebox{0.5mm}{-}\hspace{8mm}\raisebox{0.5mm}{-}200}}} &
\multicolumn{2}{l|}{\raisebox{-3mm}{\hspace{11mm}\large{:}}}&
\multicolumn{1}{c|}{} &
\multicolumn{3}{@{\hspace{1mm}}l|}{\raisebox{-2.5mm}{rest:\hspace{10.5mm}moving:\hspace{11mm}on cough:}} &
\multicolumn{1}{|c||}{\raisebox{-2.5mm}{tries/good:}}
\\[3.5mm]
\cline{1-8}
\multicolumn{1}{|@{}c@{}}{\raisebox{-1.5mm}{\textsf{\small regional}}} &
\multicolumn{3}{l}{\hspace{-2.3mm}\raisebox{-1.5mm}{$\vartriangleright$}} &
\multicolumn{4}{|@{\hspace{1mm}}l@{}}
{\raisebox{-1mm}{OK:~motor\hspace{0.7mm}\framebox{Y}\framebox{N}
~pressure\hspace{0.7mm}\framebox{Y}\framebox{N}
~block\hspace{0.7mm}\framebox{Y}\framebox{N}
~site\hspace{0.7mm}\framebox{Y}\framebox{N}
}} &
\multicolumn{1}{|c||}{\raisebox{-3mm}{\Large /}\vspace{0mm}}
\\[0mm]
\cline{2-4}
\multicolumn{1}{|@{\hspace{1mm}}l|}{~day}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.5mm}{\jane std }} &
\raisebox{-0.5mm}{\jane 0.25} &
\raisebox{-0.5mm}{\jane peth} &
\multicolumn{2}{|@{\hspace{1mm}}l}{\raisebox{0.5mm}{~~~rate\jane(ml/hr):}} &
\multicolumn{2}{@{}l}{\raisebox{0.5mm}{~~~top-ups:}} &
\multicolumn{1}{|l||}{} \\[1mm]
\cline{1-9}
\multicolumn{1}{|c}{\raisebox{-1.01mm}{\textsf{\small iv pca}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.01mm}{\jane morph}} &
\raisebox{-1.01mm}{\jane fent} &
\raisebox{-1.01mm}{\jane tram} &
\multicolumn{1}{|@{\hspace{1mm}}l}{\raisebox{-1.01mm}{bolus:}} &
\multicolumn{1}{@{}l}{\raisebox{0mm}{\raisebox{-1.01mm}{lockout:}}} &
\multicolumn{2}{r@{\hspace{1.01mm}}@{}}{\raisebox{-1.01mm}{basal\hspace{1.01mm}\framebox{Y}~taking po?~\framebox{Y}\framebox{N}\hspace{1.01mm}}} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}|}{\raisebox{-1.01mm}{\jane ketamine\hspace{6mm}ml/hr}}
\\[1.5mm]
\hline
\cline{9-9}
\multicolumn{1}{|c}{\raisebox{-4.5mm}{\textsf{\small orals}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{para}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{nsaid}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{tram}}} &
\multicolumn{1}{|@{\hspace{1mm}}l@{}}{\raisebox{-2mm}{\textit{morphine}\jane{$\frac{mg}{24h}$}}
% \raisebox{-1mm}{\Large$\vartriangleright$}
} &
\multicolumn{1}{@{}l}{\raisebox{-1.5mm}{~short:~~~~~~~}} &
\multicolumn{1}{@{}l|}{\raisebox{-1.5mm}{long:~~~~~~~~}} &
\multicolumn{1}{|@{\hspace{1mm}}l|}{\raisebox{-1.5mm}
{\textit{m'done}\jane{$\frac{mg}{24h}$}}} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-1.5mm}
{\jane clonidine~TTS~\framebox{Y}}
}
\\
\cline{2-9}
&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{3cyc}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{gaba}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{mexil}}} &
\multicolumn{4}{|l}{} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-0.7mm}{QC\hspace{2.55mm}\framebox{\scriptsize{A}}~~\framebox{\scriptsize{B}}~~\framebox{\scriptsize{C}}} }
\\[1.5mm]
\hline
\cline{1-9}
\multicolumn{1}{|l@{}@{}}{\raisebox{-1mm}{\hspace{2mm}\textsf{\small{alerts}}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{~$\Downarrow$~{\jane BP}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane sedatn}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane nausea}}} &
\multicolumn{4}{|@{\hspace{1mm}}l|}{} &
\multicolumn{1}{||@{\hspace{1mm}}l|}{\raisebox{-1mm}{\textsf{\small initials}}} \\[2mm]
\hline
\end{tabular}
% ------------
% ===========================================================================================
\begin{tabular}{|@{\hspace{1mm}}p{15mm}@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}p{19mm}p{19mm}p{17mm}p{14mm}|p{18mm}|}
\hline
\multicolumn{9}{|c|}{~\vspace{-4.8mm}}\\
\cline{1-9}
\multicolumn{4}{|@{\hspace{1mm}}c|}{\textsf{\small date\raisebox{0.1mm}{\footnotesize\hspace{0.1mm}+}time}~~~} &
\multicolumn{1}{@{}c@{}}{\textsf{\small consultant}} &
\multicolumn{3}{|l|}{\hspace{16mm}\textsf{\small pain\footnotesize{/10}}~~~~~~~~~~} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}||}{\raisebox{-1mm}{\textsf{PCEA {\jane or} PCA}}}
\\[-3mm]
\multicolumn{2}{|c}{\raisebox{-3.5mm}{\large{\hspace{5mm}\raisebox{0.5mm}{-}\hspace{8mm}\raisebox{0.5mm}{-}200}}} &
\multicolumn{2}{l|}{\raisebox{-3mm}{\hspace{11mm}\large{:}}}&
\multicolumn{1}{c|}{} &
\multicolumn{3}{@{\hspace{1mm}}l|}{\raisebox{-2.5mm}{rest:\hspace{10.5mm}moving:\hspace{11mm}on cough:}} &
\multicolumn{1}{|c||}{\raisebox{-2.5mm}{tries/good:}}
\\[3.5mm]
\cline{1-8}
\multicolumn{1}{|@{}c@{}}{\raisebox{-1.5mm}{\textsf{\small regional}}} &
\multicolumn{3}{l}{\hspace{-2.3mm}\raisebox{-1.5mm}{$\vartriangleright$}} &
\multicolumn{4}{|@{\hspace{1mm}}l@{}}
{\raisebox{-1mm}{OK:~motor\hspace{0.7mm}\framebox{Y}\framebox{N}
~pressure\hspace{0.7mm}\framebox{Y}\framebox{N}
~block\hspace{0.7mm}\framebox{Y}\framebox{N}
~site\hspace{0.7mm}\framebox{Y}\framebox{N}
}} &
\multicolumn{1}{|c||}{\raisebox{-3mm}{\Large /}\vspace{0mm}}
\\[0mm]
\cline{2-4}
\multicolumn{1}{|@{\hspace{1mm}}l|}{~day}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.5mm}{\jane std }} &
\raisebox{-0.5mm}{\jane 0.25} &
\raisebox{-0.5mm}{\jane peth} &
\multicolumn{2}{|@{\hspace{1mm}}l}{\raisebox{0.5mm}{~~~rate\jane(ml/hr):}} &
\multicolumn{2}{@{}l}{\raisebox{0.5mm}{~~~top-ups:}} &
\multicolumn{1}{|l||}{} \\[1mm]
\cline{1-9}
\multicolumn{1}{|c}{\raisebox{-1.01mm}{\textsf{\small iv pca}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.01mm}{\jane morph}} &
\raisebox{-1.01mm}{\jane fent} &
\raisebox{-1.01mm}{\jane tram} &
\multicolumn{1}{|@{\hspace{1mm}}l}{\raisebox{-1.01mm}{bolus:}} &
\multicolumn{1}{@{}l}{\raisebox{0mm}{\raisebox{-1.01mm}{lockout:}}} &
\multicolumn{2}{r@{\hspace{1.01mm}}@{}}{\raisebox{-1.01mm}{basal\hspace{1.01mm}\framebox{Y}~taking po?~\framebox{Y}\framebox{N}\hspace{1.01mm}}} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}|}{\raisebox{-1.01mm}{\jane ketamine\hspace{6mm}ml/hr}}
\\[1.5mm]
\hline
\cline{9-9}
\multicolumn{1}{|c}{\raisebox{-4.5mm}{\textsf{\small orals}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{para}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{nsaid}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{tram}}} &
\multicolumn{1}{|@{\hspace{1mm}}l@{}}{\raisebox{-2mm}{\textit{morphine}\jane{$\frac{mg}{24h}$}}
% \raisebox{-1mm}{\Large$\vartriangleright$}
} &
\multicolumn{1}{@{}l}{\raisebox{-1.5mm}{~short:~~~~~~~}} &
\multicolumn{1}{@{}l|}{\raisebox{-1.5mm}{long:~~~~~~~~}} &
\multicolumn{1}{|@{\hspace{1mm}}l|}{\raisebox{-1.5mm}
{\textit{m'done}\jane{$\frac{mg}{24h}$}}} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-1.5mm}
{\jane clonidine~TTS~\framebox{Y}}
}
\\
\cline{2-9}
&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{3cyc}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{gaba}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{mexil}}} &
\multicolumn{4}{|l}{} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-0.7mm}{QC\hspace{2.55mm}\framebox{\scriptsize{A}}~~\framebox{\scriptsize{B}}~~\framebox{\scriptsize{C}}} }
\\[1.5mm]
\hline
\cline{1-9}
\multicolumn{1}{|l@{}@{}}{\raisebox{-1mm}{\hspace{2mm}\textsf{\small{alerts}}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{~$\Downarrow$~{\jane BP}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane sedatn}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane nausea}}} &
\multicolumn{4}{|@{\hspace{1mm}}l|}{} &
\multicolumn{1}{||@{\hspace{1mm}}l|}{\raisebox{-1mm}{\textsf{\small initials}}} \\[2mm]
\hline
\end{tabular}
% ------------
% ===========================================================================================
\begin{tabular}{|@{\hspace{1mm}}p{15mm}@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}p{19mm}p{19mm}p{17mm}p{14mm}|p{18mm}|}
\hline
\multicolumn{9}{|c|}{~\vspace{-4.8mm}}\\
\cline{1-9}
\multicolumn{4}{|@{\hspace{1mm}}c|}{\textsf{\small date\raisebox{0.1mm}{\footnotesize\hspace{0.1mm}+}time}~~~} &
\multicolumn{1}{@{}c@{}}{\textsf{\small consultant}} &
\multicolumn{3}{|l|}{\hspace{16mm}\textsf{\small pain\footnotesize{/10}}~~~~~~~~~~} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}||}{\raisebox{-1mm}{\textsf{PCEA {\jane or} PCA}}}
\\[-3mm]
\multicolumn{2}{|c}{\raisebox{-3.5mm}{\large{\hspace{5mm}\raisebox{0.5mm}{-}\hspace{8mm}\raisebox{0.5mm}{-}200}}} &
\multicolumn{2}{l|}{\raisebox{-3mm}{\hspace{11mm}\large{:}}}&
\multicolumn{1}{c|}{} &
\multicolumn{3}{@{\hspace{1mm}}l|}{\raisebox{-2.5mm}{rest:\hspace{10.5mm}moving:\hspace{11mm}on cough:}} &
\multicolumn{1}{|c||}{\raisebox{-2.5mm}{tries/good:}}
\\[3.5mm]
\cline{1-8}
\multicolumn{1}{|@{}c@{}}{\raisebox{-1.5mm}{\textsf{\small regional}}} &
\multicolumn{3}{l}{\hspace{-2.3mm}\raisebox{-1.5mm}{$\vartriangleright$}} &
\multicolumn{4}{|@{\hspace{1mm}}l@{}}
{\raisebox{-1mm}{OK:~motor\hspace{0.7mm}\framebox{Y}\framebox{N}
~pressure\hspace{0.7mm}\framebox{Y}\framebox{N}
~block\hspace{0.7mm}\framebox{Y}\framebox{N}
~site\hspace{0.7mm}\framebox{Y}\framebox{N}
}} &
\multicolumn{1}{|c||}{\raisebox{-3mm}{\Large /}\vspace{0mm}}
\\[0mm]
\cline{2-4}
\multicolumn{1}{|@{\hspace{1mm}}l|}{~day}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.5mm}{\jane std }} &
\raisebox{-0.5mm}{\jane 0.25} &
\raisebox{-0.5mm}{\jane peth} &
\multicolumn{2}{|@{\hspace{1mm}}l}{\raisebox{0.5mm}{~~~rate\jane(ml/hr):}} &
\multicolumn{2}{@{}l}{\raisebox{0.5mm}{~~~top-ups:}} &
\multicolumn{1}{|l||}{} \\[1mm]
\cline{1-9}
\multicolumn{1}{|c}{\raisebox{-1.01mm}{\textsf{\small iv pca}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.01mm}{\jane morph}} &
\raisebox{-1.01mm}{\jane fent} &
\raisebox{-1.01mm}{\jane tram} &
\multicolumn{1}{|@{\hspace{1mm}}l}{\raisebox{-1.01mm}{bolus:}} &
\multicolumn{1}{@{}l}{\raisebox{0mm}{\raisebox{-1.01mm}{lockout:}}} &
\multicolumn{2}{r@{\hspace{1.01mm}}@{}}{\raisebox{-1.01mm}{basal\hspace{1.01mm}\framebox{Y}~taking po?~\framebox{Y}\framebox{N}\hspace{1.01mm}}} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}|}{\raisebox{-1.01mm}{\jane ketamine\hspace{6mm}ml/hr}}
\\[1.5mm]
\hline
\cline{9-9}
\multicolumn{1}{|c}{\raisebox{-4.5mm}{\textsf{\small orals}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{para}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{nsaid}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{tram}}} &
\multicolumn{1}{|@{\hspace{1mm}}l@{}}{\raisebox{-2mm}{\textit{morphine}\jane{$\frac{mg}{24h}$}}
% \raisebox{-1mm}{\Large$\vartriangleright$}
} &
\multicolumn{1}{@{}l}{\raisebox{-1.5mm}{~short:~~~~~~~}} &
\multicolumn{1}{@{}l|}{\raisebox{-1.5mm}{long:~~~~~~~~}} &
\multicolumn{1}{|@{\hspace{1mm}}l|}{\raisebox{-1.5mm}
{\textit{m'done}\jane{$\frac{mg}{24h}$}}} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-1.5mm}
{\jane clonidine~TTS~\framebox{Y}}
}
\\
\cline{2-9}
&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{3cyc}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{gaba}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{mexil}}} &
\multicolumn{4}{|l}{} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-0.7mm}{QC\hspace{2.55mm}\framebox{\scriptsize{A}}~~\framebox{\scriptsize{B}}~~\framebox{\scriptsize{C}}} }
\\[1.5mm]
\hline
\cline{1-9}
\multicolumn{1}{|l@{}@{}}{\raisebox{-1mm}{\hspace{2mm}\textsf{\small{alerts}}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{~$\Downarrow$~{\jane BP}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane sedatn}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane nausea}}} &
\multicolumn{4}{|@{\hspace{1mm}}l|}{} &
\multicolumn{1}{||@{\hspace{1mm}}l|}{\raisebox{-1mm}{\textsf{\small initials}}} \\[2mm]
\hline
\end{tabular}
% ------------
% ===========================================================================================
\begin{tabular}{|@{\hspace{1mm}}p{15mm}@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}c@{\hspace{1mm}}p{19mm}p{19mm}p{17mm}p{14mm}|p{18mm}|}
\hline
\multicolumn{9}{|c|}{~\vspace{-4.8mm}}\\
\cline{1-9}
\multicolumn{4}{|@{\hspace{1mm}}c|}{\textsf{\small date\raisebox{0.1mm}{\footnotesize\hspace{0.1mm}+}time}~~~} &
\multicolumn{1}{@{}c@{}}{\textsf{\small consultant}} &
\multicolumn{3}{|l|}{\hspace{16mm}\textsf{\small pain\footnotesize{/10}}~~~~~~~~~~} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}||}{\raisebox{-1mm}{\textsf{PCEA {\jane or} PCA}}}
\\[-3mm]
\multicolumn{2}{|c}{\raisebox{-3.5mm}{\large{\hspace{5mm}\raisebox{0.5mm}{-}\hspace{8mm}\raisebox{0.5mm}{-}200}}} &
\multicolumn{2}{l|}{\raisebox{-3mm}{\hspace{11mm}\large{:}}}&
\multicolumn{1}{c|}{} &
\multicolumn{3}{@{\hspace{1mm}}l|}{\raisebox{-2.5mm}{rest:\hspace{10.5mm}moving:\hspace{11mm}on cough:}} &
\multicolumn{1}{|c||}{\raisebox{-2.5mm}{tries/good:}}
\\[3.5mm]
\cline{1-8}
\multicolumn{1}{|@{}c@{}}{\raisebox{-1.5mm}{\textsf{\small regional}}} &
\multicolumn{3}{l}{\hspace{-2.3mm}\raisebox{-1.5mm}{$\vartriangleright$}} &
\multicolumn{4}{|@{\hspace{1mm}}l@{}}
{\raisebox{-1mm}{OK:~motor\hspace{0.7mm}\framebox{Y}\framebox{N}
~pressure\hspace{0.7mm}\framebox{Y}\framebox{N}
~block\hspace{0.7mm}\framebox{Y}\framebox{N}
~site\hspace{0.7mm}\framebox{Y}\framebox{N}
}} &
\multicolumn{1}{|c||}{\raisebox{-3mm}{\Large /}\vspace{0mm}}
\\[0mm]
\cline{2-4}
\multicolumn{1}{|@{\hspace{1mm}}l|}{~day}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.5mm}{\jane std }} &
\raisebox{-0.5mm}{\jane 0.25} &
\raisebox{-0.5mm}{\jane peth} &
\multicolumn{2}{|@{\hspace{1mm}}l}{\raisebox{0.5mm}{~~~rate\jane(ml/hr):}} &
\multicolumn{2}{@{}l}{\raisebox{0.5mm}{~~~top-ups:}} &
\multicolumn{1}{|l||}{} \\[1mm]
\cline{1-9}
\multicolumn{1}{|c}{\raisebox{-1.01mm}{\textsf{\small iv pca}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.01mm}{\jane morph}} &
\raisebox{-1.01mm}{\jane fent} &
\raisebox{-1.01mm}{\jane tram} &
\multicolumn{1}{|@{\hspace{1mm}}l}{\raisebox{-1.01mm}{bolus:}} &
\multicolumn{1}{@{}l}{\raisebox{0mm}{\raisebox{-1.01mm}{lockout:}}} &
\multicolumn{2}{r@{\hspace{1.01mm}}@{}}{\raisebox{-1.01mm}{basal\hspace{1.01mm}\framebox{Y}~taking po?~\framebox{Y}\framebox{N}\hspace{1.01mm}}} &
\multicolumn{1}{|@{\hspace{1mm}}c@{\hspace{1mm}}|}{\raisebox{-1.01mm}{\jane ketamine\hspace{6mm}ml/hr}}
\\[1.5mm]
\hline
\cline{9-9}
\multicolumn{1}{|c}{\raisebox{-4.5mm}{\textsf{\small orals}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{para}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{nsaid}}}&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1.5mm}{\footnotesize \textit{tram}}} &
\multicolumn{1}{|@{\hspace{1mm}}l@{}}{\raisebox{-2mm}{\textit{morphine}\jane{$\frac{mg}{24h}$}}
% \raisebox{-1mm}{\Large$\vartriangleright$}
} &
\multicolumn{1}{@{}l}{\raisebox{-1.5mm}{~short:~~~~~~~}} &
\multicolumn{1}{@{}l|}{\raisebox{-1.5mm}{long:~~~~~~~~}} &
\multicolumn{1}{|@{\hspace{1mm}}l|}{\raisebox{-1.5mm}
{\textit{m'done}\jane{$\frac{mg}{24h}$}}} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-1.5mm}
{\jane clonidine~TTS~\framebox{Y}}
}
\\
\cline{2-9}
&
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{3cyc}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{gaba}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-0.7mm}{\footnotesize \textit{mexil}}} &
\multicolumn{4}{|l}{} &
\multicolumn{1}{||@{\hspace{1mm}}l@{}|}{\raisebox{-0.7mm}{QC\hspace{2.55mm}\framebox{\scriptsize{A}}~~\framebox{\scriptsize{B}}~~\framebox{\scriptsize{C}}} }
\\[1.5mm]
\hline
\cline{1-9}
\multicolumn{1}{|l@{}@{}}{\raisebox{-1mm}{\hspace{2mm}\textsf{\small{alerts}}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{~$\Downarrow$~{\jane BP}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane sedatn}}} &
\multicolumn{1}{|@{\hspace{1mm}}c}{\raisebox{-1mm}{{\jane nausea}}} &
\multicolumn{4}{|@{\hspace{1mm}}l|}{} &
\multicolumn{1}{||@{\hspace{1mm}}l|}{\raisebox{-1mm}{\textsf{\small initials}}} \\[2mm]
\hline
\end{tabular}
\vskip -2pt
\begin{tabular}{@{}p{60mm}p{47mm}p{70mm}}
\footnotesize \textsf{Copyright \copyright\ J van Schalkwyk, 2005} &
&
\footnotesize \textsf{~DO~NOT~USE~this~form~after~1/12/2009}
\end{tabular}
}
\end{titlepage}
\setlength{\topmargin}{0pt}
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\setlength{\oddsidemargin}{0pt}
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\font\fred=cmr10 at 10truept
\title{The Analgesia Safety Checklist \\ \large A new form for Acute Pain Services \\ \normalsize Version 1.00}
\author{J.M. van Schalkwyk \\ L.A. Hopley}
\date{\today}
\maketitle
\tableofcontents
\newpage
\section{Executive summary}
This checklist is intended to improve safety in the field of acute pain. It's designed
to \emph{flow} from left to right, and from top to bottom. It covers most important checks.
The Analgesia safety checklist is designed to help you, not to `cover your arse'. Studies
and experience in medicine and other high-risk areas such as the airline industry have
shown that \textit{even in the hands of experts} the use of relevant checklists enhances performance
and lowers error rates. Fill out fields as follows:
\begin{description}
\item [\framebox{\fred Y}] is used to identify \emph{unusual} things which should be
brought to the attention of the pain team. Examples include
cardiac disease, and the use of a basal PCA infusion
\item [\framebox{\fred Y}\framebox{\fred N}] also alerts one to insert significant \emph{negative} information ---
not only do we wish to know whether the pressure areas are OK,
we also want to know if they're not!
\item [\framebox{\emph{para(cetamol)}}] Abbreviated items like this can be ticked or circled as needed.
\item [bolus: ~~~~~~~~] For such items, fill in the blank!
\end{description}
Important points:
\begin{enumerate}
\item \textit{Evaluate} the patient. Impressions are more
important than simply writing down numbers. Only write down information you have checked
personally. If you need to write a long spiel, write it in the
clinical notes.
\item To use the form optimally, there are four things you need to do:
\begin{enumerate}
\item Put a patient sticker on the top of the form;
\item Complete \textit{relevant} safety alert items at the top of the form,
writing in significant allergies, and a brief virtuoso comment if needed.
\item Complete the checklist whenever you see the patient (At
least twice a day for epidurals, at least once a day for other pain relief
modalities);
\item \textit{Respond} to problems. If the patient looks bloody ill,
make sure they are attended to by the relevant person.
(Perhaps we should have a `bloody sick' tickbox!)
If they have
motor block or are hypotensive or over-sedated, address the issue!
\end{enumerate}
\item Don't see filling out the checklist as a painful ritual. It's there to
improve safety! Just fill out the items
you consider relevant, using the checklist as a \textit{visual aid to memory}. If there's
something you think should be on the list, don't chafe about it, talk to us!
The following section discusses each field in detail.
\end{enumerate}
\newpage
\section{Form details}
Here we provide a brief justification for the existence
and structure of the form, and
then address each section, row and field in the form.
\subsection{Rationale}
Humans are fallible. Even experts get it wrong, especially when their routine
is disrupted, for example by somebody talking to them. The most important way
of preventing errors is to check things at several levels, and repeatedly. Such
checking is best done by multiple individuals, perhaps augmented by computer checks.
Checklists help us by reminding us what we need to check, and providing a visual
record of what was checked. Having safe systems with repeated checks and visual
reminders is more important than relying on an individual to perform flawlessly
(and then blaming that individual when things go wrong)!
The \textit{Analgesia safety checklist} is far from perfect, and attempts to improve it
are welcome. The basic idea behind the form is that it is a visual aid, and not
simply a ritual checklist to `prove that you did the job'. We'd rather you left
fields blank than simply copied them from the previous entry. Physically check
the items before you fill them in!
If you're not using a field, this is valuable information that either our
form is bad, or there are other system errors which need to be addressed!
\subsection{The top of the form}
It's obvious why we need to put the correct patient label on the form. On the ward,
check for duplicate names and be particularly careful if the patient folder has a
red label advising you that a duplicate name exists. This is just common sense!
Fill in the ward and bed for the patient, and keep this information updated as
the patient moves around. Put a single line through past entries.
\subsection{Safety alerts}
The idea behind this section is that by simply glancing at the top of the form, you
will be reminded about major problems relevant to good analgesia. If the patient is
in renal failure, you probably want to avoid giving morphine. If they have heart failure,
you won't be keen to use NSAIDs. If they have a bleeding diathesis and an epidural,
there's a disaster waiting in the wings. And so on \ldots
Clearly you will only be alerted to such major problems if somebody (you) has
ticked the relevant box. Also, things won't work if there's a lot of distracting
scribbling in this section, so only tick a box if you believe it's a substantial
problem. It's your call!
\subsection{Checklist structure}
Often you won't have to complete more than 3 lines:
\begin{enumerate}
\item The top line (date, time, consultant, etc);
\item A check on one modality (for example, PCA);
\item `The bottom line' --- alerts, a note, your initials, and, oh yes, the
quality control (QC) assessment of the patient's pain documentation, just above
your initials!
\end{enumerate}
Things may be more time-consuming and complex with complex patients on several
analgesic modalities, but these are precisely the patients who are at high risk,
and thus need to be checked more diligently!
\subsection{Checklist details}
\subsubsection{The top line}
Vital information is kept on the top line. It's pointless keeping a record if
there's no date and time. Likewise we need to know the initials of the pain consultant
if they were present, verbally reported
pain scores, and the quality of nursing documentation of pain issues. Let's look
at these in turn:
\begin{description}
\item[Date] Because of local conventions, we write dates as DD-MM-YYYY rather
than the international YYYY-MM-DD. Having the year nearly filled in is convenient
and mnemonic.
\item[Time] We use the twenty-four hour clock, for example 23:30. Record midnight
as 00:00 at the start of the new day, rather than 24:00 on the previous day!
\item[consultant] Only write in the initials of the relevant consultant if they
were present and saw the patient. (Helps us keep an eye on them :-)
\item[pain/10] The patient's verbal reported scores (out of 10). If the patient
can't communicate these, don't make it up, rather put in a question mark, as this
too is useful information. (You may then also wish to write a comment,
something along the lines of `comfortable' or `pain ++++').
\item Because they're so important, we've also started the PCEA/PCA documentation on the
top line. Fill out the number of tries and successes at PCA presses.
\end{description}
\subsubsection{Regional procedures}
\begin{description}
\item[regional] To the right of the $\vartriangleright$ mark, \textit{write in} the
regional modality. This will usually be `epidural', which you can abbreviate if you
wish to \textit{epi}.
\item[std/0.25/pethidine] Circle one of these common options, after checking
that the correct infusion is present.
Know the various mixtures (standard, 0.25\% bupivacaine, or pethidine).
If something arcane is being infused, make
a brief note of it in the $\vartriangleright$ area (and where necessary,
supplement this with a later comment).
\item[motor] Is motor function completely OK --- if so, tick the \framebox{Y} box.
If there's \textit{any degree} of motor block, tick \framebox{N} and respond appropriately
by stopping the epidural infusion, waiting an appropriate length of time, and then
either resuming the epidural or ordering the MRI!
\item[site] Again, only tick \framebox{Y} if things are hunky-dory. If not, document
and act.
\item[pressure] Are the pressure areas completely normal? If so, tick \framebox{Y},
otherwise tick \framebox{N} and sort things out.
\item[block] Is the block good? If so, tick \framebox{Y}, otherwise \framebox{N} and
address the issue.
\item[rate] Record the rate, taking appropriate action if you think it's excessive, or increasing
it if the patient is haemodynamically stable and pain is an issue.
\item[top-ups] Record the number of top-ups.
\item[tries/good] Don't only write down this information from the PC(E)A device, but
ask yourself ``Why?'' if the number is very low, very high, or there is discordance between
the two numbers!
\end{description}
\subsubsection{PCA}
Circle (or tick) the relevant PCA agent (morphine, fentanyl or tramadol),
if the patient is on a PCA. Then complete the rest of the line \ldots
\begin{description}
\item[bolus] Read the bolus dose from the pump. This check is slow and
mildly irritating owing to
the design of our current (Abbott) PCA pumps;
\item[lockout] What is the lockout interval in minutes? Occasionally, you'll find
this has been mysteriously programmed to something silly like twenty minutes, so
don't just write down `5' minutes! Look and see!
\item[basal] Although basal infusions are discouraged, you may encounter them.
A high-risk approach, so tick the \framebox{Y} if a basal infusion is being used!
\item[taking po?] Once the patient is taking orally well, the PCA can usually
be discontinued, which is why we have this question on the PCA line of the form!
\item[tries/good] As for regionals, record PCA usage.
\end{description}
If ketamine is being used in association with PCA for co-analgesia, there's a box
where you can record the infusion rate. You generally won't find value in going over
10ml/hr.
\subsubsection{Orals}
\begin{description}
\item[para/nsaid/tram] Most patients should be on paracetamol, but don't tick (or circle)
the item if it's not being given. Also record use of non-steroidal anti-inflammatories,
and tramadol.
\item[morphine mg/24hr] We break up this field into two:
\item[short] Refers to use of either Sevredol, or morphine elixir. Add up and
record the total dose given over the 24 hours
\emph{up until 08:00 today},\footnote{A line needs to be drawn in the sand.
Recording dose `from 24~hours ago' is a disaster if the patient
isn't seen at precisely the same time on subsequent days!}
in milligrams.
\item[long] Long acting morphine, such as M-Eslon, Kapanol, or LA morph. Add up
the total dose over the 24 hours \emph{up until 08:00 today}, in milligrams.
\item[3cyc/gaba/mexil] Specialised agents, often used for central/neuropathic pain ---
tricyclics such as nortriptyline and amitriptyline, gabapentin and mexiletine.
If the patient is on these, virtuoso comments are generally in order!
\end{description}
\subsubsection{Free text lines --- two of them!}
This area is a `one size fits all' section where you can briefly document `other therapy'.
You'll sometimes need to put in extra oral pain medication but
can potentially use this area for alerts about drugs such as:
\begin{itemize}
\item calcitonin;
\item lignocaine infusion;
\item rectally administered drugs (PR paracetamol, PR diclofenac, PR morphine);
\item certain transcutaneous drugs (fentanyl). Note that there's already a box
for transdermal (TTS) clonidine.
\end{itemize}
\subsubsection{The bottom line --- problems}
Although you will want to record all sorts of problems, (which you can do in
the white space below the checklist box, and in the patient's notes), we have
chosen three main issues. On the form we have reminders for hypotension
($\Downarrow$ BP), sedation and nausea, as we believe these are most important.
\begin{description}
\item[$\Downarrow$ BP] The relevance of substantial hypotension is clear ---
particularly with epidural analgesia;
\item[sedation] Is the patient excessively sedated? We have emphasised
sedation over `respiratory rate'
as we believe it's far more important to record whether the patient is over sedated
than simply writing down a respiratory rate. The risk comes more with excessive
sedation, which is what you should document by ticking (or circling) `sedation'.
\item[nausea] Is the patient troubled by nausea? (This is often more debilitating
than either pain or vomiting).
\end{description}
We also encourage you to comment on the quality of the relevant pain documentation
in the patient's notes using the `QC' field. Use the following conventions:
\begin{description}
\item[\framebox{A}] Clear, good quality documentation;
\item[\framebox{B}] Average quality documentation;
\item[\framebox{C}] Documentation that is unclear or difficult to read, hindering
communication.
\end{description}
By rating the notes, we are not condemning the creators of those notes, but simply
making a observation as to how we feel the system is working in this particular instance!
\subsubsection{Additional information - ``It doesn't fit''}
What if there's not enough space on the form? The form can't and won't cover
every eventuality. There are two things you can do:
\begin{enumerate}
\item Write it all out in the clinical notes. This approach keeps everyone in
the loop.
\item Use the \textit{blank line} below the checklist box to make a brief note
\textit{and} indicate that you've written all the gory details in the clinical notes!
\end{enumerate}
\newpage
\section{Design rationale}
This form is still very tentative, and recommendations to improve it
will be welcomed.\footnote{\LaTeX was used to create the form, as we found it
gave us more control over design. Our editor was WinEdt version 5.}
Our rationale for various `design features' (quirks?) is as follows:
\begin{itemize}
\item Serif fonts have been used predominantly, to improve legibility;
\item We have largely avoided use of uppercase, as such usage impairs readability;
\item We have not used shading, because this impairs legibility and quality of
copies, as well as vastly increasing the size of digitised files;
\item Epidural and PCA have been combined on one form to allow for the possibility
of this combination in real life;
\item 'Vital information' --- date, time, initials of consultant (if present),
and level of pain --- has been placed
on the top line to ensure that these are brought to the attention of the user.
Flow is logically from left to right in this and the subsequent lines;
\item The next lines in turn deal with major aspects of epidural, pca and
oral therapy. In accordance with the associated acuity, the epidural has been allocated
substantial space. Oral drugs generally used for `neuropathic' or complex pain have
been placed on a new line, with a free-format comment area nearby;
\item We have tried to resist the temptation to capture too much information.
The assumption is made that if there are problems with motor function, pressure areas,
the epidural site, or the block, then further documentation will be made of such problems
in the patient notes. The problem list has similarly been limited to three major
problems (nausea, sedation and hypotension) as we regard these three as critical;
\item We have specified \textit{either} PCA \textit{or} PCEA as the reasonable assumption
is made that use of the two together will not occur, as such usage is confusing for
any patient. If the patient is on PCA, the implication is that they are \emph{not}
on PCEA!
\item \textit{Oral} items have been shown in italics to set them off from other therapy;
\item The use of morphine is displayed prominently in italics, and we have subdivided
this usage into `short' and `long' acting (Sevredol versus M-Eslon, LA morph, and so on).
We have avoided using trade names;
\item Apart from morphine, we have limited the commonly used oral options.
This choice is for reasons of space and frequency of use.
\item Form users are encouraged to use initials to save time and facilitate
identifying user and consultant.
\item We have avoided using \emph{boxes} for numeric data such as pain on rest and
movement, rates, and so forth, in order to improve form legibility\footnote{Often
form users don't keep within the bounds of such boxes, anyway!}
\item Only three epidural options are provided (standard mix i.e. 0.125\% bupivacaine
with $2 \mu$g/ml fentanyl; 0.25\% bupivacaine, or pethidine) --- but the rather
ugly blank space above can be used to document other options, as well as
\emph {other regional infusions} of local anaesthetic;
\item The term `failure' has been used to characterise what otherwise might be termed
`organ dysfunction' (or whatever) to emphasise that we are interested in
substantial `dysfunction' which has an effect on our pain therapy!
\end{itemize}
\section{Possible improvements}
\begin{itemize}
\item At present total PCA dose isn't documented, but this might be inserted in
the `PCA or PCEA' box, at the expense of clarity;
\item Consider having a `see notes' checkbox somewhere prominently displayed!
\end{itemize}
\section{Translation to PDA format}
Implementation of data capture on a personal digital assistant (PDA)
is discussed in an accompanying
document called \emph{PDA data capture based on a form template}.
\section{Availability}
The \LaTeX ~source for the Analgesia safety checklist is made available under the
GNU Public Licence (GPL) at \href{http://www.anaesthetist.com/analgesia/}{http://www.anaesthetist.com/analgesia/}
\end{document}
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